Contents

List of Figures vii List of Tables viii List of Charts ix Notes on Contributors x Acknowledgements xii Introduction xiv A Guide to the Book xvii

Part I Nursing Skills and Concepts 1 1 Managing Nursing Care 2 Richard Hogston 2 Social Behaviour and Professional Interactions 22 Phil Russell 3 Challenges to Professional Practice 46 Steve Tee 4 Developing Skills for Reflective Practice 70 Melanie Jasper

Part II Nursing Interventions 93 5 Infection Control 94 Somduth Parboteeah 6 Administration of Medications 104 Somduth Parboteeah 7 Eating and Drinking 137 Sue M. Green 8 Elimination 162 Barbara A. Marjoram 9 Respiration 194 Jan Dean, Pamela Diggens and Rob Haywood

v vi Contents

10 Circulation 216 Chris Walker 11 Wound Management 238 Pam Jackson, Lynn Taylor and Nadia Chambers 12 Moving and Handling 267 Wayne Arnett and Kevin Humphrys 13 Dying, Death and Spirituality 291 Phil Russell 14 Drug and Alcohol Misuse 319 Anita Green

Part III Professional Issues 347 15 Body Image and Sexuality 348 Sid Carter and Anita Green 16 Genetics Knowledge within an Ethical Framework 369 Delia Pogson 17 Nursing Practice in an Interprofessional Context 392 Janet McCray 18 Public Health in Nursing 413 Elizabeth Porter 19 Health Informatics 440 Adam Keen and Neil Hosker 20 Developing Effective Leadership and Management Skills 466 Yvette Cox 21 Answers to Test Yourself! Questions 491

Index 499 Chapter Richard Hogston 1 Managing Nursing Care

Contents

• What is the Nursing Process? • Stage 5: Evaluation • Stage 1: Assessment • Information Technology and • Stage 2: Nursing Diagnosis Care-planning • Stage 3: Planning Nursing Care • Chapter Summary • Stage 4: Implementation • Test Yourself! • Managing Nursing Care in the • References Clinical Environment

Learning outcomes

The purpose of this chapter is to explore how nurses manage care; it will take you through a five-stage problem-solving approach known as the nursing process. At the end of the chapter, you should be able to: • Define the stages of the nursing process • Undertake a nursing assessment • Identify nursing diagnoses from the assessment data • Devise and implement a plan of care • Evaluate your actions • Consider the link between evaluation and quality of care. Throughout the chapter, a working example using a client who is experiencing pain will be used to demonstrate how each of the stages of the nursing process is applied. The chapter also provides an opportunity for you to undertake some exercises that will assist you with your care-planning skills.

2 Managing Nursing Care 3

What Is the Nursing Process?

The nursing process is a problem-solving framework that enables the nurse to nursing process plan care for a client on an individual basis. The nursing process is not under- a five-stage problem- taken once only, because the client’s needs frequently change and the nurse must solving framework enabling the nurse to respond appropriately. It is thus a cyclical process consisting of the five stages plan individualised care shown in Figure 1.1. for a client The nurse is an autonomous practitioner whose responsibilities are now governed by The Code: Standards Assessment of Conduct, Performance and Ethics for Nurses and Midwives, devised by the Nursing and Midwifery Council (NMC, 2008). This requires nurses to be accountable for Evaluation Diagnosis the care that they prescribe and deliver and to ‘keep clear and accurate records of the discussions [they] have, the assessments [they] make’ (NMC, 2008). Today, one’s ability to use the nursing process is governed by the stand- ards for pre-registration nursing education (NMC, 2010) Implementation Planning as outlined by the statutory body, the NMC, and embed- ded in parliamentary statute (DoH, 2000). The standards Figure 1.1 The nursing process state that conditional to registration is the ability to: Make a holistic person centred and systematic assessment of physical, emotional, psychological, social, cultural and spiritual needs, including risk and develops a comprehensive personalised plan of nursing care. (NMC, 2010) Failure to keep a record of nursing care or to use the nursing process can lead to a breakdown in the quality of care that is provided. The Clothier Report (DoH, 1994), which was published following the inquiry into Beverley Allitt (the nurse who was convicted of the murder of children in a hospital in Grantham, Lincolnshire), noted how: Despite the availability of a nurse with responsibility for quality management, there were no explicit nursing standards set for ward four. In addition the nursing records were of poor quality and showed little understanding of the nursing process. High Quality Care for All (Darzi, 2008) states that clinicians’ first and primary duty will always be their clinical practice or service, delivering high quality care to patients based on patients’ individual needs. Therefore, the importance of understanding and using a systematic patient-centred approach (such as the nursing process) to the provision of nursing care cannot be overestimated. There has been some debate within the profession over the number of stages nursing diagnosis needed in the nursing process, some suggesting four and others five. With a the second stage of the four-stage approach, the nurse does not have time to reflect on the assessment nursing process, often data that have been collected and instead moves from assessment to planning. described as a ‘nursing The five-stage process enables the nurse to identify the client’s problem’, for which the nursing diagnosis nurse can independently in order to plan the appropriate care. prescribe care 4 Richard Hogston

The nursing process should not be seen as a linear process: it is a dynamic and ongoing cyclical process (Figure 1.1). Assessment, for example, is not a ‘one-off’ activity but a continuous one. Take the example of the individual who is in pain – it is not enough to make a pain assessment that may warrant an intervention; the nurse then needs to make a reassessment after having evaluated whether the pain-relieving intervention has been successful. The nursing process is a problem-solving activity. Problem-solving approaches to decision-making are not unique to nursing. The medical profes- sion uses a specific format based upon an assessment of the body’s systems. A number of questions are asked in a systematic manner to enable the doctor to make a diagnosis based upon the information that has been collected. Problem- solving approaches are also taken outside the health-care field. Car mechanics undertake a sequence of activities in order to diagnose what is wrong with your car when you tell them that there is a squeak or a rattle.

Stage 1: Assessment Sources of assessment data PPActivity 1.1 Before beginning to consider what sort of information you might need to collect, we need to look at the skills that are necessary to ensure that the data analysed Think about the client and other sources are comprehensive. Assessment is not an easy process as it includes collecting that you may be able information from a variety of sources. The quality of the assessment will, how- to consult to assist ever, depend on one’s ability to put together all the sources at one’s disposal. you when conducting a comprehensive Spend a few minutes on Activity 1.1. assessment. Write The sources that you have listed in Activity 1.1 have probably included the them down in a list. following: • Your client • Relatives, friends and significant others • Current and previous nursing records • The records of other health professionals such as doctors and physiotherapists • Statements and information from the police, ambulance personnel, witnesses at an accident scene and others. Your client The first and most important source for data collection is from the individual whom you are assessing. It will not, however, always be possible to obtain all the information you require, for a number of reasons, so you will also need to consult other people. Relatives, friends and significant others If you are assessing a baby, most of the verbal information you require will be obtained from his or her parent(s) or guardian(s). With a child, you will need to qualify some of your information through the same source. In the case of Managing Nursing Care 5 an adult who is unconscious or is having difficulty breathing, you will again need to obtain data from friends, relatives, ambulance personnel, the police and so on. The same applies if the client has difficulty understanding as a result of dementia or severe learning disabilities. Nursing, medical and other records It will not always be possible to have immediate access to existing records, espe- Link cially in an emergency or with a first consultation, but these sources hold valu- Chapter 19 has more able information that you need to analyse. They provide details that may assist information on IT and prompt you. If the client has been admitted to a hospital, you may have a initiatives. letter from the GP, district nurse, health visitor or community psychiatric nurse. Similarly, on discharge from hospital, you will provide discharge information if community-based professionals need to be involved. Telephone calls to these professionals, visits and case conferences may also feature. As the roll out of the national programme for IT within the NHS occurs the use of electronic patient records should enable much faster access to a range of data (www.connecting- forhealth.nhs.uk).

Skills PPActivity 1.2 Spend a little while Having considered some of the sources at your disposal, we now need to think thinking about about what other factors have a bearing on a successful assessment. Spend a few what kinds of skills minutes on Activity 1.2. you need in order As we are beginning to see, the process of assessment is a complex one. to conduct your assessment. Write Although we have identified some of the sources of information, the quality of them down in list the information collected depends upon a number of other factors. In your list form. from Activity 1.2, you may have included: • Listening • Physical examination Link • Observing • Measurements. Chapter 2 contains a detailed examination • The use of verbal and non-verbal of how the nurse communication and open and can most effectively closed questions use some of these skills. You may wish Listening to consult this before One of the most important features of an assessment interview is the nurse’s reading on. ability to listen to the client. This means giving the client time to answer ques- tions. You will appreciate from your own life experience that when you are asked a question, you want time to think and then answer without interruption. A premature interruption may lead to clients withholding information or not feeling that you are really interested in what they have to say. Although it is important for you to focus on the information you require and not digress, the fact that Mrs Jones has been admitted as an emergency and is meant to be on the school run in an hour will be the only thing of interest to her until you are able to contact someone who can collect her children. 6 Richard Hogston

Observation Link Observation can in itself provide the nurse with a great deal of information. The bluish tinge (cyanosis) seen around the mouths, nailbeds and faces of some Chapters 9 and 10 explain some causes breathless patients may be indicative of respiratory distress and will be an indi- of cyanosis and cation of how little oxygen is circulating in their blood. A yellowish tinge to the identify the difference skin (jaundice) may be indicative of biliary disease. Similarly, facial and other between central and peripheral cyanosis. body expressions may give you an indication of pain. Open and closed questioning closed questions Both these methods of communication need to be used when collecting informa- those designed to elicit tion. The use of closed questions allows the client who is, for example, breath- a simple ‘yes’ or ‘no’ less, anxious, in pain or depressed to answer with a simple ‘yes’ or ‘no’. Open answer questions, however, will allow you to provide your clients with a full opportu- open questions nity to tell you the history of their illness or pain. those in which clients can express their answers Chapter 2 discusses open and closed questions in more detail. in as many words as they choose Physical examination pyrexia The physical examination of clients allows you to observe and make a judge- fever, body temperature ment about their symptoms. You will be able to determine the integrity (state) elevated from normal of the skin, which is an important consideration in an immobile client. Physical Link damage such as wounds can be seen, as can even the small puncture marks left Chapter 11 has a by an intravenous drug abuser. Skin that feels very warm and moist to the touch section on wound may be a sign of pyrexia. assessment. Measurements Link Measurements come in many forms, for example the taking of a blood pressure, Chapter 10 explores pulse or temperature. Also included here is the use of other assessment tools blood pressure and explains how to take such as a nutritional analysis, a pressure ulcer risk calculator (use the tool used an arterial blood in your locality, for example Braden or Waterlow) or a pain chart. pressure reading. Data collection

PPActivity 1.3 As we have seen, nurses must, in order to be able to plan care for their clients, be able to gather information that will enable them to make informed decisions. Select a friend or relative and ask them But what information do nurses need to gather, what questions should they if you can spend ask and how much do they need to know? The answer is determined on an about 20 minutes individual basis, the nurse collecting both subjective and objective information. undertaking a health Before looking in detail at what information should be collected, undertake assessment. Now take a blank piece Activity 1.3. of paper and collect From the activity, in addition to name, age and date of birth, you may have the information that collected some of the following information: you feel is important when making some Physical health information decisions about your • Current and past health problems • Patterns of activity and rest chosen person’s Nutritional and dietary information Stamina health status. • • Managing Nursing Care 7

• Physical parameters • Dental, hearing, vision and so on • Factors affecting health (cigarettes, • Elimination patterns alcohol and so on) • Sexual history. Psychological information • How does the client react to stress, • Communication challenge and so on? • Values and beliefs. • What are the person’s hopes, expectations, demands? Social health information • What is the person’s lifestyle? • Leisure • Employment/unemployment details • Exercise • Family or other responsibilities • Social environment/networks. How did you decide what you needed to ask, how did you decide to word the questions, and did you collect everything to enable you to feel that you had conducted a thorough assessment?

Framework for assessment One way of organising the information that you need to collect is by using a PPActivity 1.4 nursing framework. The ‘activities of living’ framework devised by Roper et al. Read Holland et al. (2008) uses a list of the client’s activities of living (Chart 1.1) as a framework (2008) for further for assessment, the nurse systematically collecting the physical, psychological, reading related to the sociocultural and economic aspects of these activities. activities of living.

Chart 1.1 The activities of living

••Maintaining a safe environment ••Controlling body temperature ••Communicating ••Mobilising ••Breathing ••Working and playing ••Eating and drinking ••Expressing sexuality ••Eliminating ••Sleeping ••Personal cleansing and dressing ••Dying

Breathing, one of the activities of living, will now be used as a framework to demonstrate the type of information that the nurse needs to collect during an assessment. At any given time during the assessment process, it may be necessary to concentrate more on one activity than another. Breathing The information that the nurse needs to collect about this and any other activ- Link ity of living depends on the answers to certain trigger questions. You may, for Chapter 9 example, start off by asking your client whether she has any problems with provides methods breathing. Even though the answer may be ‘no’, you would, as a professional, of respiratory need to investigate further. The client whom you are assessing may not feel that assessment. she has a problem with breathing, but consider the following questions: 8 Richard Hogston

1 ‘Do you smoke?’ The answer here may be ‘yes’ even though the client has said she has no problems with breathing. Indeed, she may still feel that she does not have any problems. This is, however, a trigger for further questioning. 2 ‘Do you suffer from any breathlessness?’ The answer at the outset may again be ‘no’, but if you ask about running up the stairs or running for a bus, the client may admit that, yes she does then, but this is because she does not usually do any exercise. 3 Taking this one step further allows the nurse to extract even more informa- tion about the status of the client’s breathing: ‘Do you cough?’ The answer may be ‘no’, but when prompted the client may admit to coughing for a little while in the morning, although this clears rapidly and she thinks noth- ing of it. If the client is a normal healthy young adult, the nurse may at this stage still perceive that the client does not actually have a problem with breathing in the short term even though she is partaking in health-damaging behaviour. In the long term, however, the consequences of smoking could be fatal. At this stage in the assessment process, it may be sufficient to make a note of the information gathered so far; when it comes to planning care, the action that will be pre- scribed will then include health education about smoking. This will be expanded on in the section on planning and implementation below.

Summary and worked example PPActivity 1.5 This section has introduced you to the nursing process and looked in some detail at assessment. The activities should have enabled you to experience some of Read the client profiles in Casebox the issues that you need to consider when undertaking a nursing assessment. 1.1. Choose one of the We have examined the skills that the nurse needs to use when assessing clients, profiles and, for any and we have been introduced to one assessment framework that may assist the two of the activities of living, write down the nurse during the process. By way of a summary of the information that needs information that you to be gained when undertaking an assessment, the following section takes pain would need to collect as an example and outlines the questions and methods that can be employed during a nursing when assessing a client’s pain. This will be revisited as we consider the other assessment. four stages of the nursing process later in the chapter. Having read this sum- mary, you may like to return to the client profile you chose and identify the information you feel would be important for your chosen profile. Alternatively, you might like to take the opportunity to participate in the assessment process during your practice placements in the common foundation programme.

Pain assessment

Link The assessment of pain is a complex activity that involves a consideration of the physical, psychological and cultural aspects of the individual. Because pain is a Chapter 10 deals with pain arising from subjective experience, the nurse needs to be able to summarise the information circulatory problems. gained against some objective criteria. This is essential for diagnosis and for evaluating the effectiveness of interventions. Only the person experiencing the Managing Nursing Care 9

Joan Harris is a 69-year-old of distress – hitting her face, lifting Alison Simpson, 21 years old, lives lady who tripped and fell over a her jumper and crying. At first it in a hostel for people with mental protruding pavement slab this was thought that this might be health problems. She has no close morning while out shopping. because of premenstrual tension. family, having left home at 18. She has been admitted to the After a while, however, someone She finds it difficult to develop

Casebox 1.1 orthopaedic ward of her local thought to arrange a dental relationships and is suspicious of NHS Foundation Trust hospital inspection under anaesthetic: the people who try to befriend her. suffering from a fractured neck dentist found a particularly nasty Alison is very withdrawn and of femur. Mrs Harris is pale and is dental abscess (adapted from has on two occasions attempted anxious about who will look after NHSE, 1993). to take her own life through her cat while she is in hospital. She an unsuccessful paracetamol is complaining of severe pain in her Andrew Holly is 5 years old and overdose. She was found this hip and knee, and has grazes and has been admitted to the accident morning slumped in a corner, cuts to her lower leg. and emergency department of covered in blood and complaining the local NHS Trust hospital. He of extreme pain in her left hand. Amanda Cohen is 29 years old and is complaining of a very sore and On the floor nearby was a razor has profound learning disabilities. painful arm, is withdrawn and is blade, and on examination she She lives in staffed residential sobbing. He is accompanied by his had severe lacerations to her left accommodation with two other mother, his 2-year-old sister and forearm. young women. For two weeks, their newborn baby brother. Amanda has been showing signs pain knows its nature, intensity, location and what it means to them. One of the most seminal, widely used and accepted definitions of pain was put forward by McCaffery and Beebe (1999), who suggest that pain is ‘what the person says it is existing when and where the person says it does’. Assessments of the patient’s pain experience To begin with, it is essential to identify the characteristics of the client’s pain. This means that the nurse should consider: • The type of pain: is it crampy, stabbing, sharp? How the client describes biliary the pain may help in diagnosing its cause. Myocardial (heart) pain is often pertaining to bile, bile described as stabbing, but biliary pain as cramping or aching. ducts or gall bladder • Its intensity: is it mild, severe or excruciating? Pain assessment scales are helpful here. The nurse can ask the patient to rate the pain on a scale of 0 to 10, zero being no pain and 10 intolerable pain. With children, a range of pictures showing a child changing from happy to sad can be used. Colour ‘mood’ charts, with a series of colours from black through grey to yellow and orange, have also been used and are very useful for clients who have difficulty grasping numbers or articulating exactly what their pain is like. • The onset: was it sudden or gradual? Find out when it started and in what circumstances. What makes it worse? What makes it better? What was the patient doing immediately before it happened? • Its duration: is it persistent, constant or intermittent? • Changes in the site: there may be tenderness, swelling, discolouration, firmness or rigidity. With appendicitis, a classic sign is the movement of pain from the umbilicus to the right iliac fossa. In a myocardial infarction (a heart 10 Richard Hogston

attack), pain classically radiates down the arm, and with biliary pain it can radiate to the shoulder. • Its location: ask the patient to be as specific as possible, for example indicat- ing the site by pointing. • Any associated symptoms: Chart 1.2 shows some of the common symptoms of disease that can influence the response to pain. • Signs such as redness, swelling or heat.

Chart 1.2 Common symptoms of disease that influence the response to pain

••Anorexia ••Nausea and ••Oedema ••Malaise and vomiting ••Immobility lassitude ••Cough ••Anxiety and fear ••Constipation ••Dyspnoea ••Depression ••Diarrhoea ••Inflammation ••Dryness of the mouth

Summary Table 1.1 provides a summary of some of the issues to consider when assessing pain. In essence, this section demonstrates how much detail the nurse needs to collect when making a full assessment of the client’s pain. Consider your own experiences of pain, both personally and from clients you have nursed in clinical practice, and reflect on how comprehensive the assessment was then.

Stage 2: Nursing Diagnosis The second stage of the nursing process is making a nursing diagnosis. This enables the nurse to translate the information gained during the assessment and identify the nursing problems. In order to avoid confusion, it is worth noting that ‘diagnosis’ is not a concept unique to medicine: car mechanics diagnose mechanical problems, teachers diagnose learning difficulties, and consequently

Table 1.1 Assessment of pain Initial sympathetic responses to Parasympathetic responses Verbal responses Muscular and postural pain of low-to-moderate intensity to intense or chronic pain responses Increased blood pressure Decreased blood pressure Crying Increased muscle tone Increased heart rate Decreased heart rate Gasping Immobilisation of the affected area Increased respiratory rate Weak pulse Screaming Rubbing movements Decreased salivation and Increased gastrointestinal Silence Rocking movement Gastrointestinal activity activity Dilated pupils Nausea and vomiting Drawing up of the knees Increased perspiration Weakness Pacing the floor Pallor Decreased alertness Thrashing and restlessness Cool, clammy skin Shock Facial grimaces Dry lips and mouth Removal of the offending object Managing Nursing Care 11 nurses diagnose nursing problems. The language of nursing diagnosis originated in North America in an effort to move the art, science and theoretical basis of nursing forward and readers are advised to visit the informative website at www.nanda.org. Nursing diagnosis is a critical step in the nursing process; it depends on an accurate and comprehensive nursing assessment and forms the basis of nursing care-planning. Nursing diagnosis is the end-product of nursing assessment, a clear statement of the patient’s problems as ascertained from the nursing assess- ment (Roper et al., 2008). Furthermore, the International Council of Nurses has, for the purposes of the International Classification for Nursing Practice, defined a nursing diagnosis as ‘a label given by a nurse to the decision about a phenomenon which is the focus of nursing intervention’ (ICN, 1999). A visit to the website at www.icn.ch is recommended for more detailed information and to appreciate the collaborative work on nursing diagnosis and the International Classification for Nursing Practice is progressing. The key components of what constitutes a nursing diagnosis are outlined in Chart 1.3. Link Chart 1.3 Key components of a nursing diagnosis Chapter 8 considers ••A nursing diagnosis: ••Is a short concise statement the causes, diagnosis and treatment of ••Is a statement of a client’s problem ••Consists of a two-part statement constipation. ••Refers to a health problem ••Is a condition for which a nurse can ••Is based on objective and subjective independently prescribe care assessment data ••Can be validated with the client PPActivity 1.6 ••Is a statement of nursing judgement Return to the two Source: Adapted from Shoemaker (1984); Bellack and Edlund (1992); Iyer et al. (1995). activities of living that you assessed during Activity 1.5. Try to Making a nursing diagnosis identify one actual Nursing diagnoses can be actual or potential. Actual diagnoses are those which and one potential nursing diagnosis. are evident from the assessment, for example pain caused by a fractured neck Use the guidelines in of femur. Potential diagnoses, on the other hand, are those which could or will Chart 1.3 to ensure arise as a consequence of the actual diagnoses. For example, an individual who that your diagnoses is normally active but is confined to bed is at risk of becoming constipated or meet the criteria. developing a pressure sore. In this instance, two potential diagnoses arise: Activity 1.7 • a potential risk of constipation as a result of enforced bedrest PP • a potential risk of pressure sore development from enforced bedrest. For the diagnoses that you identified during Activity 1.5, try to identify one short-term and one Stage 3: Planning Nursing Care long-term goal for your chosen client. There are two steps to the planning stage: Remember to ensure that they meet the • Setting goals MACROS criteria • Identifying actions. (see below for description). 12 Richard Hogston goal A goal is a statement of what the nurse expects the client to achieve and is the intended outcome of sometimes referred to as an objective. In other words, goals are the intended a nursing intervention, outcomes and can be short or long term. Goals are client centred and must be sometimes referred to as an objective realistic, being stated in objective and measurable language. They help both nurse and client to define how the nursing diagnosis will be addressed. Goals serve as the standard by which the nurse can evaluate the effectiveness of the nursing actions. When writing goals, they need to conform to the MACROS criteria; they should be: • Measurable and observable so that • Realistic the outcome can be evaluated • Outcome written • Achievable and time limited • Short. • Client centred Using the example of pain, the short-term goal will be that the client will state that he is comfortable and pain free within 20 minutes. The long-term goal, however, is that the client will state within 12 hours that he feels in control of his pain. (It is important to remember to take account of the non-verbal clues discussed earlier – is the client really pain free?) With the move to shorter hos- pital stays and the emphasis on care in the community, it may not always be necessary to formulate both long- and short-term goals for all problems. It is, however, always better to have a number of short-term goals that are reached so that new goals can be set rather than having a long-term goal that takes weeks to achieve. With Mrs Harris (see Casebox 1.1 above), who will have surgery for her hip, this will be a series of goals that progress her towards full mobility fol- lowing her operation, for example: ‘Mrs Harris will walk one way to the toilet unaided by [enter date]. Mrs Harris will be able to climb one set of stairs by [enter date].’ This avoids a long-term goal that reads ‘Mrs Harris will be fully mobile by [enter date].’

Action planning The next stage is to plan the nursing care that will ensure that clients achieve their goals. This is where the nurse prescribes nursing actions that can then be implemented and evaluated. In ‘care-planning’ language, these are the nursing actions – the prescribed interventions that are put into effect in order to solve the problem and reach the goal. It is against these actions that the nurse may, when evaluating care, have to make some adjustments if the actions have not been effective. In today’s NHS, when we are seeing a decreasing number of registered nurses against an increase in those of bank and agency nurses and unqualified health-care support workers, documenting the prescribed nursing care ensures a degree of continuity. In this way, the care plan can be seen as the diary of the client’s nursing care. When planning nursing care, use the REEPIG criteria, which will ensure that your plan of care is: • Realistic: it is important that the care can be given within the available resources, otherwise it will not be achievable. Managing Nursing Care 13

• Explicit: ensure that statements are qualified. If you suggest that a dressing needs changing, state exactly when. This will ensure that there is no room for misinterpretation. • Evidence based: nursing is a research-based profession. When planning nursing care, the research findings that underpin the rationale for care must be considered. • Prioritised: start with the most pressing diagnosis. Given that time is of the essence, the first priority may be, for example, to plan care for the client’s pain. • Involved: the plan of care should involve not only the client, so that he or she is aware of why such care is needed, but also the other members of the health-care team who have a stake in helping the client back to health, for example physiotherapists and dietitians. • Goal centred: ensure that the care planned meets the set goals. Returning now to the example of pain, the nurse needs to make decisions about what sorts of intervention will most effectively relieve Mrs Harris’s pain. This involves not only decisions about prescribed medications, but also other con- siderations such as how often the pain assessment tool should be used and what alternative non-pharmacological methods, such as comfort through pillows, the use of skin traction for the leg and distraction therapy, can be implemented. The nursing care plan for Mrs Harris may therefore detail the following nursing actions: • Give the prescribed analgesic and monitor its effects; record them on the Link pain chart Chapter 11 examines • Apply skin traction (if appropriate) pressure ulcer grading • Nurse on a bed equipped with pressure-relieving equipment and risk assessment • Ensure regular changes of position and assessment of equipment needs to achieve this while encouraging independence; encourage Mrs Harris to PPActivity 1.8 change her position regularly Return to the client • Ensure that Mrs Harris has a supply of chosen reading/writing materials and for whom you chose to identify nursing access to the television/radio/MP3 player. diagnoses and goals. Consider what nursing care you would need to plan in order to achieve those Stage 4: Implementation goals. Implementation is the ‘doing’ phase of the nursing process. This is where the nurse puts into action the nursing care that will be delivered and addresses each of the diagnoses and their goals. The nurse will undertake the instructions writ- ten in the care plan in order to assist the client in reaching these goal(s). This will involve a process of teaching and helping clients to make decisions about their health. It also involves deciding upon the most appropriate method for providing nursing care, and the liaison and involvement of other health profes- sionals. Look at the list of health professionals in Chart 1.4. Do you know what their primary roles and functions are and when you might need to involve them? 14 Richard Hogston

Chart 1.4 Other members of the health-care team

••Physiotherapist ••Health visitor ••Occupational therapist ••Community ••District nurse ••Dietitian psychiatric nurse ••Podiatrist GP ••Key worker ••Speech therapist ••Social worker ••School nurse

Managing Nursing Care in the Clinical Environment A number of different approaches to the delivery of nursing care are available to nurses. These include task allocation, patient allocation, team nursing, primary nursing, the key worker and caseload management. The benefits or otherwise of each of these methods need to be considered in the light of the skill mix of available staff (that is, the number and grade of qualified and unqualified staff) and what it is that the nursing team wants to achieve. It is difficult to evaluate the right approach without considering the benefits or drawbacks of each of these methods. The published reports of clinical governance reviews by the Care Quality Commission (www.cqc.org.uk) considers the management and organi- sation of nursing care as well as the quality of care and record keeping.

Task allocation task allocation Task allocation (also known as functional nursing) is a highly ritualistic method the provision of nursing of organising care that centres on nurses and support workers being assigned care that centres on a tasks. With this system, one nurse will be assigned to undertake the observations range of tasks allocated to nurses/support of temperature, pulse, blood pressure and respiration. Another nurse undertakes workers all the dressings, whereas another takes care of the drugs. This is a fragmented method of providing nursing care that will ensure that the client receives aspects of care from a multiplicity of nurses and support workers, akin to a production line process. The emphasis on tasks naturally removes the notion of individual- ised client care and as such is incompatible with the nursing process.

Client allocation client allocation Client allocation is where the total care for a number of clients is undertaken by individualised care one nurse, often assisted by a support worker. Although this system means that provided by a named there is an emphasis on total client care being delivered by an individual nurse nurse, often assisted by a support worker for a designated period of time, continuity of care may become compromised if the same clients are not cared for on a regular basis by the same nurse. With this system, extra attention needs to be paid to the detail in the nursing care plan because of the number of nurses who may have contact with a client.

Team nursing team nursing Team nursing occurs where a designated group of clients is cared for by a team care provided by a team of nurses/support of two or more nurses (at least one of whom is a registered nurse) who accept workers led by a ‘team collective responsibility for the assessment, planning, implementation and leader’ Managing Nursing Care 15 evaluation of the clients’ care. Although each team will be headed by a team leader, each registered nurse is accountable for his or her actions in accordance with the Code (NMC, 2008). This is important to remember in an effort to counteract any criticism surrounding who is ultimately responsible under a sys- tem of collective responsibility. Walsh and Ford (1989) have described how team nursing and client alloca- tion evolved as the successor to task allocation on the premise that being cared for by a team rather than an array of nurses led to more holistic care. They suggested that team nursing really resembles a small-scale version of task alloca- tion, especially if there is a lack of continuity between shifts when the same team may not be on duty, leading to fragmentation of care. Consequently, there has to be a commitment to ensure that tasks are not assigned to each team member. Team nursing has received a positive press from student nurses. Lidbetter’s (1990) small-scale study describes how students working in a hospital ward practising team nursing spent more time working alongside a qualified nurse and rated their skill acquisition and their evaluation of the effectiveness of client care higher than did those from a ward practising primary nursing. Students were also, as a learning experience, afforded the opportunity to assume the role of team leader, under supervision.

Primary nursing

Primary nursing has been described as a professional patient-centred practice primary nursing (Manley, 1990). In this approach, the primary nurse accepts full responsibility care provided on an and accountability for his or her clients during their stay. In its purest form, the individual basis by a named nurse who, in its implication is that the primary nurse has 24-hour responsibility 7 days a week purest form, holds 24 (Manthey, 1992). In reality, a team of associate nurses continues to provide nurs- hour accountability for ing care under the direction of the primary nurse and in his or her absence. Again, the package of care accountability and autonomy rest with the individual registered nurse under the Code of Conduct (NMC, 2008). Positive effects of a move to primary nursing can be seen in the literature (Laakso and Routasalo, 2001; Drach-Zahavy, 2004).

Person-centred planning Popular in the field of learning disabilities, a person-centred approach to plan- ning care is advocated in the White Paper Valuing People Now (DoH, 2009a). Person-centred planning starts with the individual, and is at the heart of enabling people with highly complex needs to lead fulfilling lives.

Care programme approach Focusing on personalised planning supporting individuals with severe mental illness, DoH (2008) provides comprehensive guidance on the care programme approach. Useful links are signposted with other assessment and planning frameworks, such as person-centred planning highlighted above. 16 Richard Hogston

Caseload management

Link This is the most popular method of organising nursing care in the community set- ting. It revolves around the designated named nurse with extended qualifications Chapter 18 has more information on how in health visiting/district nursing who acts as the caseload manager. Caseloads teams interface are normally organised either geographically or by GP attachment, each caseload between hospital, manager leading a team of qualified nurses and health-care support workers. home and other community settings. Continuity of care is maintained because the teams are organised to ensure that a member of the team is available every day of the week; as such, it is less affected by the demands of the shift system. Each registered nurse is accountable for his or her own actions (NMC, 2008), the caseload manager being responsible for ensuring that the skill mix and resources are adequate. Given the shift of care PPActivity 1.9 from the secondary to primary setting and the role of the community matron, keeping patients out of hospital by managing long-term conditions in the com- From your own experiences in munity will see this method of managing care increase (DoH, 2009). clinical practice, what method(s) of care organisation have you Stage 5: Evaluation experienced? Write down two positive At the beginning of this chapter, it was noted that the stages of the nursing pro- aspects and then cess need to be seen as ongoing rather than as once-only activities. This means consider whether one that the final stage, evaluation, is in reality the end of the beginning and where of the other methods described above the process in essence restarts. One of the key components of quality nursing would have been practice is the nurse’s ability to make a clinical judgement based upon a sound suitable and why. knowledge base. Evaluation is about reviewing the effectiveness of the care that has been given, and it serves two purposes. First, the nurse is able to ascertain whether the desired outcomes for the client have been achieved. Second, evalu- ation acts as an opportunity to review the entire process and determine whether the assessment was accurate and complete, the diagnosis correct, the goals real- istic and achievable, and the prescribed actions appropriate. Increased health-care costs require managers throughout the professions to reduce expenditure and seek the most cost-effective options. The population at large are also more informed about health-care matters and are arguably less passive recipients of health care, demanding a detailed and open explanation for their care (Hogston, 1997). It is therefore the responsibility of each nurse to ensure that the prescribed care takes account of these issues. Given that nursing records are legal documents that could be used in a court of law, extreme care and accuracy are essential when completing the care plan to which the registered nurse puts her signature. In its guidance on record keeping the NMC states that ‘good record keeping is a mark of a skilled and safe practitioner, while careless or incomplete record keeping often highlights wider problems with that indi- vidual’s practice’ (NMC, 2007b). In order to raise standards of care, and in keeping with the clinical govern- ance agenda, the government has published benchmarks in fundamental aspects of care (DoH, 2010a), one of which focuses on record-keeping. Readers should familiarise themselves with this particular benchmark. It is important to note Managing Nursing Care 17 that the document stresses that the best interests of people are maintained throughout the assessment, planning, implementation, evaluation and revision of care and development of services and when a system for continuous improve- ment of quality of care is in place.

Methods of evaluating nursing care Having discussed the importance of evaluation and the place it has in maintain- PPActivity 1.10 ing quality, it is important to consider some of the methods that nurses can use. How do you think First of all, undertake Activity 1.10. that nursing care is Your list, from Activity 1.10 may have included some of the following: evaluated? You may have witnessed some • Nursing handover • Patient satisfaction or complaint methods in your own • Reflection • Reviewing the nursing care plan. clinical placements; write them down as Nursing handover a list. If you have not, try to think generally You may have had experience of a nursing handover, which is where a team about how you of nurses hand over information about the nursing care of clients to another evaluate any service you have received – group of nurses, usually at the end of a shift, for example from day care to buying a meal or an night care. Using the nursing care plan as the focus, nurses share information item from a shop, for about the clients and their planned care. This serves as a valuable forum for example. evaluating care through a discussion of its effectiveness. The variety of experi- ences and professional expertise held by a number of nurses allows a sharing of that information. The importance of nursing handover was stated by the Audit Commission (1992) as being critical for maintaining continuity of client care.

Reflection

The role of reflection in quality and evaluation has been discussed in some detail Link in the literature, and Chapter 4 discusses the concept in more detail. Reflection Chapter 4 reviews can, however, be both formal and informal. You probably reflect on your expe- types of reflection, riences both socially with other friends who are nurses and more formally in thoughtful practice lecturer-led tutorials. This leads to an analysis of your actions and some of the and reflection in practice settings. ways in which you could have done things differently or which you would want to repeat. The use of critical incident analysis, for example, enables nurses to evaluate a given situation or event; this is a tool that is used by qualified nurses in their personal portfolios, which must be kept in order for the nurses to be eligible for triennial re-registration.

Patient satisfaction The appreciation that is sometimes offered by clients through, for example, a letter, is an indicator of how satisfied individuals have been with their nurs- ing care. In contrast, a letter of complaint may lead to an investigation into the reasons why a client has not been satisfied with the care received. Although the number of letters of complaint appears to be on the increase, this is probably the result of a culture comprising a more informed public. In many ways, such letters 18 Richard Hogston

lead to an analysis of what went wrong; this may not necessarily be a result of poor nursing care but of other environmental factors. Hopefully, however, such publicity allows those who have control over resources to evaluate the priorities. Health-care providers are now required to publish statistics on indicators of quality ranging from, for example, how long clients have to wait in accident and emergency departments to the number of clients who receive a visit from the community nurse within the two-hour appointment time. In the same vein, letters and cards of satisfaction should be closely monitored.

Reviewing the nursing care plan This is where the nurse evaluates the effectiveness of the care that has been given against the set goals and writes an evaluation statement. When evaluating care, it is useful to ask yourself a series of questions about each of the stages of the nursing process, which will provide you with answers about your plan of care: • Have the short-term goals been met? • If the answer is ‘yes’, has the diagnosis been resolved? If so, it no longer needs to be addressed. • If the answer is ‘no’, why have the goals not been met? Did they meet the MACROS criteria? • Was the planned care realistic? Did it meet the REEPIG criteria? • Has a new diagnosis arisen or a potential diagnosis become an actual one? • Was the method of care delivery appropriate? • Was there effective communication within and between the nursing staff and other members of the multidisciplinary team? • How satisfied was the client with the care? Finally, take a look at the completed care plan for Mrs Harris outlined in Table 1.2 and compare it with your own completed care plan.

Table 1.2 Worked example of a care plan for Mrs Harris Nursing diagnosis Pain due to fractured femur Short-term goal Mrs Harris states that she is comfortable with a pain scale rating below 2 within 15 minutes Long-term goal Mrs Harris feels that she is in control of her pain and that it is no longer a major concern for her within 24 hours Nursing actions Give the prescribed analgesic and monitor its effects Apply skin traction Nurse on a bed equipped with a pressure-relieving mattress Ensure two-hourly changes of position by attaching a trapeze pole to the bed, and encourage Mrs Harris to change her position regularly Ensure that Mrs Harris has a supply of chosen reading/writing materials and access to the television and radio Evaluation Mrs Harris states that she is comfortable and her pain scale rating remains below 2. Managing Nursing Care 19

Information Technology and Care-planning PPActivity 1.11 Review the The input of information technology to health care is having a significant impact assessment, nursing on the NHS as advanced computerised information systems record and evaluate diagnosis, goal(s), everything from finance to personal records. From your own experiences, you planned care may already have seen laptop/palm-top and office-based computers that can and method of implementation for record client details and an analysis of nurses’ workload. As the NHS network your chosen client expands, all health-care workers are able to access electronic records, email and and then write an increasingly the World Wide Web. This will provide nurses with rapid access to evaluation statement. client data such as previous nursing records. There are also currently a number Remember to ask the questions outlined in of care-planning computer packages used by different NHS Trusts. the text. Computerised care-planning offers the nurse a number of advantages. It is quick, because there are a number of templates for common nursing diagnoses. Link Although these are sometimes criticised for moving towards a more communal Chapter 19 has more rather than an individualised approach to nursing care, each of the templates information on has a menu of options that can be tailored to the individual client. The ability to computerised care planning and the use raise at the push of a button a client’s previous records is also an advantage and of IT in health care. generally allows a more rapid search than does a paper-based system. Computerised care-planning is, however, only as effective as the person who operates the system and generates the care plan. The skills of assessment, identifying nursing diagnoses and goal-setting, and the required nursing actions, can only be effective if the nurse has a sound knowledge base and uses the skills outlined within this chapter. The profession should, and indeed does, welcome the move to more electronic-based systems, if only because the approach is fast and usually efficient. The government has published its national programme for IT; a visit to its interactive website at www.connecting forhealth.nhs.uk is recommended in order to view the implementation plan and appreciate the rapid advances in this area. However, following the publication of the Coalition Government’s White Paper (DoH, 2010) the future of a national approach to IT is under consideration.

Chapter Summary This chapter has introduced you to a systematic method for delivering nursing care through the framework known as the nursing process. You have been intro- duced to the five basic stages of assessment, diagnosis, planning, implementation and evaluation. Using the vehicle of structured activities, you have been offered the opportunity to develop a care plan for a chosen client. At this stage, you may feel that the nursing process is a complex activity that demands a great deal of thought and practice, but your skills and experi- ences will continue to grow and develop as your professional career continues. Working through a structured chapter such as this is no substitute for practice and experience, but the principles of care-planning and the issues you need to consider are offered as the basis of accountable nursing practice. You may, for example, have been surprised at how complex and comprehensive the process of 20 Richard Hogston

assessment is. The depth of material that you needed to collate when undertak- ing your assessment may have led you to reflect on the importance of probing and accurate questioning. As you progress in your chosen professional career, you will find that your ability to plan care will become greater. The important point to remember is that the whole practice and process of nursing is ever changing, new strategies, treatments and knowledge arriving almost daily. New research informs nursing practice and must be incorporated into one’s profes- sional repertoire. The process of nursing, like the process of learning, is an ongo- ing rather than a once-only activity.

? Test yourself!

1 Name the stages of the nursing process. 2 Give two reasons for using the nursing process. 3 What sort of information needs to be collected during a nursing assessment? 4 How many types of nursing diagnosis are there? 5 What are the two stages of the planning phase? 6 What criteria should goals conform to? 7 How can the nursing care plan be evaluated?

References Audit Commission (1992) Making Time for DoH (Department of Health) (2008) Refocusing the Patients: A Handbook for Ward Sisters. HMSO, Care Programme Approach: Policy and Positive London. Practice Guidance. DoH, London. http:// Bellack, J.P. and Edlund, B.J. (1992) Nursing www.dh.gov.uk/en/Publicationsandstatistics/ Assessment and Diagnosis, 2nd edn. Jones & Publications/PublicationsPolicyAndGuidance/ Bartlett, London. DH_083647 (accessed 29 2009). Darzi, Lord A. (2008) High Quality Care for All DoH (Department of Health) (2009) Supporting (Cm. 7432, 2008) [Internet], Department People with Long-term Conditions: of Health, London. http://www.dh.gov.uk/ Commisioning Personalised Care Planning: A en/Publicationsandstatistics/Publications/ Guide for Commissioners. DoH, London. http:// PublicationsPolicyAndGuidance/DH_085825 www.dh.gov.uk/en/Publicationsandstatistics/ (accessed 29 June 2009). Publications/PublicationsPolicyAndGuidance/ DoH (Department of Health) (1994) The Allitt DH_093354 (accessed 29 June 2009). Inquiry: Independent Inquiry Relating to DoH (Department of Health) (2009a) Valuing Deaths and Injuries on the Children’s Ward at people now: a new three year strategy for people Grantham and Kesteven Hospital during the with learning disabilities. DoH, London. http:// Period February–April 1991 (Clothier Report). www.dh.gov.uk/prod_consum_dh/groups/ HMSO, London. dh_digitalassets/documents/digitalasset/ DoH (Department of Health) (2000) Nurses, dh_093375.pdf (accessed 6 October 2010) Midwives and Health Visitors (Training) DoH (Department of Health) (2010). Equity Amendment Rules Approval Order 2000. and Excellence: Liberating the NHS. Cm 7881. Stationery Office, London. London: Department of Health. Available at: DoH (Department of Health) (2001) Valuing www.dh.gov.uk/en/Publicationsandstatistics/ People: A New Strategy for Learning Disability Publications/PublicationsPolicyAndGuidance/ for the 21st Century. Stationery Office, London. DH_117353 (accessed on 5 October 2010). www.valuingpeople.gov.uk/dynamic/valuing- DoH (Department of Health (2010a) Essence of people136.jsp Care 2010: Benchmarks for the fundamental Managing Nursing Care 21

aspects of care. DoH, London. http://www. Manley, K. (1990) Intensive care nursing. Nursing dh.gov.uk/prod_consum_dh/groups/ Times 86(19): 67–9. dh_digitalassets/@dh/@en/@ps/documents/ Manthey, M. (1992) The Practice of Primary digitalasset/dh_119978.pdf (accessed 6 Nursing. King’s Fund, London. October 2010) NHSE (National Health Service Executive) (1993) Drach-Zahavy, A. (2004) Primary nurses’ Learning Disabilities. DoH, London. performance: role of supportive management. NMC (Nursing and Midwifery Council) (2007) Journal of Advanced Nursing 45(1): 7–16. Record Keeping. NMC, London. http:// Hogston, R. (1997) Nursing diagnosis: a position www.nmc-uk.org/aDisplayDocument. paper. Journal of Advanced Nursing 26: aspx?documentID=4008 (accessed 29 June 496–500. 2009). Holland, K., Jenkins, J., Solomon, J. and Whittam, S. NMC (Nursing and Midwifery Council) (2008) The (2008) Applying the Roper-Logan-Tierney Model Code: Standards of Conduct, Performance and in Practice, 2nd edn. Churchill Livingstone, Ethics for Nurses and Midwives. NMC, London. Edinburgh. www.nmc-uk.org ICN (International Council of Nurses) (1999) NMC (Nursing and Midwifery Council) (2010) International Classification for Nursing Practice. Standards for pre-registration nursing education. ICN, Geneva. NMC. London. http://standards.nmc-uk.org/ Iyer, P.W., Taptich, B.J. and Bernocchi-Losey, D. Pages/Downloads.aspx (accessed 6 October (1995) Nursing Process and Nursing Diagnosis, 2010) 3rd edn. W.B. Saunders, Philadelphia. Roper, N., Logan, W. and Tierney, A. (2008) The Laakso, S. and Routasalo, P. (2001) Changing to Roper-Logan-Tierney Model of Nursing Based primary nursing in a nursing home in Finland: on Activities of Living. Churchill Livingstone, experiences of residents, their family members, Edinburgh. and nurses. Journal of Advanced Nursing 33: Shoemaker, J. (1984) Essential Features of a Nursing 475–83. Diagnosis. In Kim, M.J., McFarland, G. and Lidbetter, J. (1990) A better way to learn? Nursing McLane, A. (eds) Classification of Nursing Times 86(29): 61–4. Diagnoses. C.V. Mosby, St Louis. McCaffery, M. and Beebe, A. (1999) Pain: Clinical Walsh, M. and Ford, P. (1989) Nursing Rituals: Manual for Nursing Practice, 2nd edn. Mosby, Research and Rational Actions. Butterworth St Louis. Heinemann, Oxford. Index

ABCDE assessment, for clients with mental illness 133 amino acids 140–1, 249, 378 resuscitation 200, 207 reconstituted powder 115 see also proteins abscesses, as complication of rectal 129–30 anaemia 144, 199, 206, 221, 224, 384 intramuscular injection 120, 327 right medication 107 analgesic ladder 303 acceptance right amount 107–8 analgesics 166, 228, 302, 336 unconditional 24, 26, 34 right route 110–11 non-opioid 302 accessory muscles of respiration 197, right time 109 anastomosis 175 202 right patient 109–10 anomie 35 accountability subcutaneous 121–2 anorexia 10, 148, 169, 176, 303, 354 in clinical governance 422 rectal 129–30 anthropometric measures 150–1 in wound care 243–4 topical 124 antibiotics 95, 106, 172, 174, 180, 186, professional 15, 47, 51, 55, 65, 89, 462, transdermal 125–6 251, 299 464, 467 vaccines 122–3 anti-embolic precautions 232–3 student nurse 56 vaginal 131 antimuscarinic 185 acetone 123 adrenaline 221, 234 antioxidants 142 acidosis 195, 197, 199, 202 agglutination 234 apnoea 197, 201, 202 action planning 12 AIDS 303, 327, 335, 337 sleep apnoea 148, 203 activities of living (AL) 7 airway appetite 142, 147–8, 152, 170, 322, 332, adaptation and body image 356 ABCDE 200, 207 336, 338 adenosine triphosphate (ATP) 200 chronic obstructive pulmonary aprons 97, 99, 287 Administration of Medicines 104–34 disease 129 arrhythmia 133, 218, 220, 228, 231, 338 Assessment 105 Guedel’s (oropharyngeal) 208 sinus arrhythmia 221, 232 Ear 126–7 maintenance 207 arterial ulcers 245 eye 125–6 nursing interventions 228 artificial respiration,see resuscitation oral 111–2 patency 207 ascites 158, 332 injections 114–16 suctioning 209 ascorbic acid, see vitamin C intradermal 123 see also respiration aseptic technique 99, 125, 180, 188 intramuscular 116–21 alcohol 320–3, 328–33, 419, 434 aspects of health 244, 415, 419, 426, medication adherence 131–2 assessment 339–40 434, 441 medication errors 134 binge drinking 327 assertiveness 23, 36, 38–43 nasal 127–8 diet contribution 142, 144, 149, 388 broken record technique 41 nasogastric tube 112 effects on body 170, 179, 182, 197, fielding the response 41 nebuliser 128–9 330–3 fogging 42 oral 111–12 government guidelines 330 ‘I’m OK, you’re OK’ quadrangle 39 parenteral 113 guidelines and pregnancy 332 managing criticism 42 patient safety, five Rs 106–7, 133, 235 unit calculator 330 saying no 41 preparations 115–16 use 329 techniques 41–2 precriptions 106 theories specific to alcohol assessment 1 principles of administration to misuse 333 of alcohol and drugs 339–40 children 132–3 withdrawal 323 circulatory 219–22 clients with learning alkalosis 195 drug administration 105 difficulties 133 alpha-linolenic acid 141 ergomomics 278

499 500 Index

framework for 3–5, 7–10 haemolytic mismatch 234 health and social 268, 386, 393, 394, health needs 418 body ideal 351–2 396, 407 moving and handling 284–8 body image 352–3 inverse care law 420 normal bowel habit 166 altered 354, 355–5 planning 11–12, 19, 237, 298, 358 nursing assessment tools 11 adaptation 356 preventative 403 nutritional 146, 149–51 concealed image 352, 354–5 quality of 3, 14, 62, 64, 66, 393, 457 of pain 8, 10, 227 ‘loss of self’ model 353 standards of 16, 55, 56, 65, 78, 244, pain assessment tools/scales 244 open image 354–5 422, 468 patient 105 body mass index (BMI) 150, 258 care models, see nursing models respiratory 200–1 body piercing 355 care planning 11–12, 19, 237, 298, 358 physical 201–4 body presentation 351–2 action planning 12–13 sexuality 354–6 body reality 352–3 goals, MACROS criteria 12, 18 wound care 245–8, 257–61 boundaries, professional 49, 393, 397, information technology and 19 asthma 202–5, 212–13, 336 398–9 REEPIG criteria 12–13 and genetics 370, 385 Braden scale 6, 245, 247–8 steps in 3 atrial fibrillation 217, 220, 222, 232 bradycardia 220–1, 228, 343 care standards, see standards of care attitude 25, 32, 34, 61, 63, 301, 315, 320, bradypnoea 197, 201 caseload management 14, 16 341, 349–51, 353–4, 360–1, 400, 429 brain death 294 catalytic category 28–30 see also behaviour; beliefs; personality; breast awareness 433 cathartic category 30–1 values breastfeeding 343 catheters audit, clinical 65–6, 244, 406, 463 breathing, see respiration urinary, see urinary catheters Audit Commission 17 Bristol Stool Chart cell reconstruction, in wound authenticity (genuineness) 25 Adult 167 healing 249 autolysis 262 Child 168 Centre for the Advancement of autonomy 27, 37, 49, 61, 371, 373, 407, British National Formulary 107, 132 Interprofessional Education, Primary 429 British Pharmaceutical Codex 105 and Community Care 400, 408 British Pharmacopoeia 105 chain of infection 96 bacteria 95, 97, 114–15, 165, 173, 180, burns 187, 218, 222, 235, 243, 355 chemotaxis 239 235, 240–1, 251, 253 buttocks, injection site 117 Cheyne–Stokes respiration 201, 202 bad news, breaking of 32–3, 42 child protection work, ethical bed sores, see pressure sores caffeine, causing diarrhoea 139, 155, dilemmas 401 behaviour and value systems 26 173, 179, 182, 321, 322 children beliefs 7, 29, 48, 58–9, 61, 75, 80, 177, calcium 145 consent 51, 53 284, 299, 307, 314, 351, 357, 360, 429 Caldecott Report 1997 464 drug administration 132–3 see also attitude; values cannabis 322, 324–8, 335–6 ear and eye medication 126–7 beneficence 49, 61, 76, 371 cancer enuresis 179, 182 bereavement 76, 292, 296, 305, 310–12 and genetics 382, 385 faecal elimination development 164 dual-process model 311 National Service Framework 459 heart rate 220 see also grief Our Healthier Nation 295 intramuscular injection sites 120 beta-blockers 220 capillary buds 240, 254 medication administration 110, 111 biofeedback 185 capillary refill time 224 nasal medication 128 Biot’s respiration 201–2 carbohydrates 140, 164, 172 nasogastric tube 112–13 blood carbon dioxide 195, 197–9, 202, 206, rectal medications 130 clotting 158, 233 211, 212, 217 respiratory pattern of newborn 197 transfusion 233–5 carcinoma, colonic and rectal 164 subcutaneous injections 122 viscosity 222 cardiac arrest 220, 221, 228–9, 230, 323, stool chart 168 see also thrombosis 334, 483 urinary elimination blood pressure 199, 218, 219, 221, see also resuscitation development 178–9 222–4 cardiac failure 199, 220, 226 see also under individual subject hypertension 124, 217, 223, 224, 228, cardiac monitoring 230–2 headings 323, 332, 338 cardiac output 217, 221, 223, 226, 228, cholecalciferol, see vitamin D hypotension 199, 202, 224, 228, 234, 229, 334 cholesterol 141, 143, 217 323, 343 cardio-pulmonary resuscitation (CPR) chronic obstructive pulmonary disease Korotkoff sounds 223–4, 446 196, 395 (COPD) 129, 200, 202–5, 209–10, blood transfusion 233–5 care 212–13 allergic reactions 234 competent 62 Choosing Health: Making Healthier circulatory overload 234 duty of 243–4, 272 Choices 415, 426 cold blood 235 Essence of 138, 172, 243–4, 261, 423 chromosomes 374, 375–89 disease transmission 235 holistic 15, 54, 296, 364 circulation Index 501

anti-embolic measures 232–3 confronting interventions 27, 31–2 bereavement 76, 292, 296, 305, blood pressure 199, 218, 219, 221, congruence 24–5 310–12 222–4 consent 47, 49, 51–3, 64, 76, 83, 113, brain death 294 blood transfusion 233–5 130, 154, 159, 277, 283, 285, 287, 308, ethical issues 307–10 cardiac monitoring 230–2 364, 370–1, 373–4, 384, 389, 463, 486 euthanasia 308 fluid balance 143, 172, 219, 225, 226, children 53 grief 30, 292, 310–12, 356 235 rights 52 health promotion 295–6 heart rate 10, 220, 232, 337, 450 constipation 10, 130, 146, 165, 166 last offices 306–7 intravenous fluid therapy 235 causes 166, 169 pain and symptom control 302–3 claudication 228 client care 170 paliative care 296 client allocation 14–15 enemas 170 physician assisted suicide (PAS) 309 clinical governance 14, 16, 46, 65–6, 244, laxatives 165, 166, 170, 172, 174, decubitus ulcers, see pressure sores 422, 423, 434, 463, 485 manual evacuation 171–2 deep vein thrombosis (DVT) 218, 232–3 clinical practice, monitoring 244 with overflow 173 see also anti-embolic precautions clinical supervision and reflection 86, signs and symptoms 170 defaecation, see faecal elimination 244 suppositories 170 dehiscence, as complication of wound clinical waste 99, 100–1 continuing professional healing 252 safe disposal 100 development 66, 89, 244 dehydration closed questions 5, 6, 28, 30 control of infection 95, 181 as fluid balance mechanism 132, Clostridium difficile (C-Diff) 95–6 chain of infection 96 143, 150 Clothier Report 3 HCAI (health care associated diarrhoea causing 172 Cocaine and crack cocaine 324, 325, infection) 95–6 predisposing to urinary stone 327, 335, 338 controlled drugs 106–7, 324 formation 180 Code of Professional Conduct (NMC) 3, coronary heart disease 148, 217, 224, delegation 403, 473–5, 488 15–16, 47–9, 53–5, 58–9, 76, 244, 228, 385, 389, 433 deltoid muscle, injection site 116–17, 272, 275, 283, 358, 365, 433, 474, 475, Corrigan’s pulse waterhammer 221 122 477, 485–6 counselling 23, 24, 27, 176, 297, 339, deoxyribonucleic acid (DNA) 371, 374, collaboration 393, 395–400, 403, 408–9 356, 387 376–82 see also co-operation; interprofessional creatinine clearance test 180 depolarisation 321 collaboration; teamwork Credé manoeuvre 185 dermatitis from drug contact 114 collagen, synthesis 240 critical analysis 76, 78 desire 362 colostomy 174–5, 177 critical incident analysis 17, 88 detrusor–sphincter dyssynergia 185 colour, see cyanosis; skin Crohn’s disease 164, 172, 175, 355 diabetes 133, 148, 179, 181, 185, 189, communication cultural issues 77, 139, 177, 183, 269, 217, 242, 250, 258, 259, 355, 370, 385, and assertiveness techniques 41 272, 274, 285, 310, 321, 327, 358, 361, 405, 429, 433, 459 in caring for the dying 298, 303–5, 400, 427, diagnosis, see nursing diagnosis 307 cyanosis 6, 199, 202, 224, diarrhoea 10, 101, 146, 166, 174, 235, in moving and handling 271, 277, cystitis 186 303, 323, 325, 332, 336, 343 282–3, 285–6 cystic fibrosis 213, 370, 384 causes 172 in multi-professional practice 54–5, cytotoxic drugs 114, 186 patient care 172–3 398, 403, 406, 409, 417 dichotomous interventions 30 in record keeping 55 Darzi 3, 64, 364, 458 diet non-verbal 41 data collection 4, 6–7, 417, 447, 453, appetite influences 147–8 see also therapeutic communication; 463 assisting clients 154 therapeutic interventions; data information and knowledge 441, carbohydrates 140, 164, 172 manager 444–7 causing constipation 169 community corruption 443, 464 causing diarrhoea 172 involvement 427 holding 460–1 economic influences 146 three dimensions 417 implications for nursing 447–8 ethical issues 159 community care 362, 394, 396, 403, 405, integrity 451, 463 fat 141–2 408, 425 obtaining 462 fluid 155 compliance 95, 253, 271, 468, 477 recording 463 foods and nutrients 139–46 Computer Misuse Act 460, 462 sharing 464 functional foods 153 computer records 451 use 463 history 149–50 see also Data Protection Act 1984; Data and wisdom hierarchy 446 macronutrients 139–40 Protection Act 1998; records Data Protection Act 1998 50–1, 432, micronutrients 143–4 confidentiality 49–50, 53, 64, 76, 356, 460, 461 non-starch polysaccharide 143 370–1, 374, 387, 403, 442, 452, 460, death nutritional needs 146–7 463–4 awareness of 292–3 Plate Model 152 502 Index

political influences 146–7 interventions 342–3 evidence-based education/care/ promoting 152–3 psychological interventions 340 practice 47, 56–8, 63, 65, 81, 243–4, proteins 140–1 routes of adminstration 326–7 305, 363, 412–13, 433, 454, 456, screening and assessing status 149 stage of change model 341 excoriation 175, 258, 263 social influences 146–7 substance use and misuse 321–4, expiratory reserve volume 208 support 156–7 328–9 extravasation 235, 239 vitamins, see vitamins syndrome of dependency 322 eye contact 29–31, 40 285 see also fats/fatty acids; food; nutrients; DVT, see deep vein thrombosis eyes, medications 125–6 nutrition; plate model dying dignity 49, 76, 118, 121, 123, 284, 286, choice and priorities of care 298–9 faecal elimination 287, 294, 296, 307, 309, 364, 373 communication in caring for 303–5 adolescents 164 Disability Discrimination Act 275, 286 health promotion and 295–6 adults 164–5 discrimination, antidiscriminatory symptom control 302–3 ageing adults 165 practice 361, 364, 371, 373, 374 see also palliative care altered 166 district nurses 394, 396, 404 dyspareunia 177 assessment 166 diuretics 166, 179, 183, 225, 234 dyspnoea 10, 201–2, 214 constipation 166–71 diurnal 180 diarrhoea 172–3 diverticular disease 166, 172, 175 ears, medications 126–7 incontinence 173–4 DNA (deoxyribonucleic acid) 371, 374, ECGs 219, 229–33 in infants 164 376–82 echoing 29, 38 school-aged children 164 ‘doing for’, in palliative care 301 economic influences, on diet 146 specimen collection 165 Doppler testing 225 egalitarian relationships 429 toddlers to preschool age 164 dorsogluteal injection site 117–18, electrocardiograms (ECGs) 229–33 see also stoma 8 120–1 elimination, see faecal elimination; urinary Family Doctor’s Charter 404 Down’s Syndrome 169, 381 elimination; mobility fats/fatty acids drugs embolism, see anti-embolic precautions; cholesterol, see cholesterol assessment 105–6 pulmonary embolism hydrogenated fats/oils 142 adherence 131–2 ELIOT 285–7 mono-unsaturated 140, 142 cannabis 322, 324–9, 335–6 Environment 286 omega-3 141–2, 149 causing constipation 166 Load 286 omega-6 141–2, 149 classifications 325 Individual 286 polyunsaturated 141–2, 249 cocaine and crack cocaine 324, 325, Other 287 saturated 141–2, 153 327, 335, 338 Task 287 fibroblasts 239–41, 252 controlled 106, 107, 302, 324 empathy, empathic understanding 25 fibronectin 240 cytotoxic 114, 186 employees, duties under the Health and flatus 173, 177 MAOI 105 Safety at Work Act 1974 273 fluid drug errors 134 employers balance 226 Misuse of Drugs Act 1971 321, 324–5 responsibilities under the Health and charts 226 prescriptions 106 Safety at Work Act 1974 273 intake 145–6, 149, 155 common abbreviations 108 empowering, in palliative care 299, 301 intravenous fluid therapy 235 routes of administration 110, 14 enemas 130, 166, 170–1, 174 lack of, causing constipation 169 schedules 325 enteral feeding 111, 113, 156, 159, 172 see also hydration see also medication; medication enterostomies 157 fluid balance administration; topical gastrostomy 139, 157–8 maintaining, in diarrhoea 172 medications; and individual drugs jejunostomy 157 recording 226 and drug types enuresis 179, 182 fogging 42 drugs and alcohol epidemiology 414–15 folate 143 alcohol calculator 330 epithelial cells 164, 240, 242 food addiction 321 epithelialisation, in wound healing 240 infected, causing diarrhoea 172 assessment 339–40 ergocalciferol, see vitamin D Plate Model 152 classification of Mental and ergonomics 278–80 social factors 146 Behavioural Disorders (ICD-10) eschar 255, 260, 262 see also diet; nutrition 322 essential fatty acids 141, 249 foreign bodies desire, compulsion 323 ethics in urinary system 180 tolerance 323 child protection work 401 in wounds 253 withdrawal 323 interprofessional practice 401 Freedom of Information Act 2000 50–1, definitions 320–1 ethical framework 460, 462 harm reduction 342 principles 49, 61 friction – types and use 281–2 pharmacological evaluation, of nursing care 3, 15, 16–17 fulcrum 281 Index 503 functional foods 153 haemostasis, coagulation 239 Health Services and Public Health Act fungating wounds 242, 245, 252 handling, see moving and handling 1968 405 handwashing/ hand hygiene 95, 97–8, Health Strategies 457 gastrocolic reflex 163, 174 101, 154, publications and related documents to gastrointestinal tract, lower 163 indications for 5 Health Informatics 457 gastrostomy tube feeding 139, 157–8 technique 98 heart disease 148, 217, 224, 228, 297, gender 349, 356, 360 HCAI (health care associated 303, 433 gender and sexual orientation 361–2 infection) 95–6 and genetics 373, 385, 389 genes 375–9, 380–4, 388 head tilt 125, 207 heart rate 10, 219–23, 231–2 carrier testing 384 healing, see wound healing see also circulation; cardiac; pulse genetic health heparin 108, 121, 233 code 377–8 assessment of need 416–18 hierarchy of evidence 57–8 determinism 373 behavioural 415 HIV infection, AIDS 235, 327, 335, 342, ethical framework 371–4 biomedical 415 431 impact on health 385–6 care needs 420–1 holistic 3, 15, 54, 248, 257, 282, 284, 296, inheritance 374–5, 382–5 caseload profiling 416 349, 363–4, 415, 423, 429 make-up 371, 382–3, 388 community profiling 416 hospice 76, 292, 296–7, 305, 314 pharmacogenetics 388–9 definition 415 HORUS 460 profiling 386–7 improvement 428–30 data use 463 screening 387–8 influencing levels of health 419 Holding data 460–2 solidarity and altruism 371–3 postmodernist 415 Obtaining data 462 testing 374, 381, 384, 387–8 practice profiling 416 Recording data 463 genotype 382–6, 389 protection 430–1 Sharing data 464 genuineness 24–6 social 415 Human Rights Act 1998 275–6 Gibbs reflective framework 59 school health profile 416 Huntington’s Disease 370, 382, 384–5 gloves 97, 99, 111–12, 114, 116, 124–8, surveillance and assessment 416–21 hydrogenated fats/oils 142 130–1, 188, 287 Health and Safety at Work Act hydroxylation 249 glucose 140, 143, 200, 249–5, 259, 338 1974 100, 272–3 hyperpnoea 202 goals 11–13, 16, 18, 63, 90, 149, 262, 283, employees’ duties 273 hypertension 124, 217, 223–4, 228, 323, 288, 298, 341, 393, 397, 400, 403,459, employers’ general duties 273 332, 334, 338, 429 468–72, 480 health and well-being 53, 427, 433 hypertrophic scarring 252 governance Healthcare Commission 23, 428 hypotension 199, 202, 224, 228, 234, framework 244 health care 323, 343 information 460 costs 16 hypotonic bladder 185 granulation tissue 240–3, 251–2, 255–6, cultural competence 61–2 hypoxia 195. 198–200, 207, 210, 213, 260, 262 policy 47, 64–5 221, 228–9 Greenhalgh Report 395 informatics 441–3 grief 310 team 13, 14, 53, 63, 404–7 ileal conduit 190 dual process model of health care associated infection ileostomy 175, 177 bereavement 311 (HCAI) 95–6 implementation 3, 13–14, 264, 275, 278, grief-work 310 health gain 423, 429–30 424, 433, 451, 469, 472 see also bereavement Health Informatics 440–6 impotence 133, 177, 355, 359 groups data, information and incision, surgical 242, 252 description 35 knowledge 444–7 incontinence leadership 36 definition 441 faecal 165, 173–4 processes 37 implications for nursing 447–8 urinary 165, 179, 182–6, 189, 191, 259 self-help groups 356 patient care record system 451 infarction 9, 217, 221, 223 service user 396 patient journey 442–3, 452 infection 63, 124, 126, 146, 158, 165, working together 34–5 point of care 453 173, 179, 181, 184, 189, 204, 235, 241, see also teams; teamwork putting patient first 450 249, 307, 327, 337, 431, 434, 443, 469 Guedel’s (oropharyngeal) airway 208 systems based approach 449–53 chain of 96 health professional as Information as complication of intramuscular haematoma, as complication of wound manager 444 injection 120 healing 252 health promotion 152, 295, 405, 416, as complication of wound haemolysis 234–5 426, 428–30, 434, 459 healing 251, 253, 255 haemophilia 384–5 and diet 152 cross 144, 327 haemoptysis 204 and dying 295–6 health care associated (HCAI) 95–6, haemorrhage, as complication of wound framework 429, 459 431 healing 252 health protection 431–2 infection control 504 Index

aseptic technique 99 iodine 123, 143, 256 physical self 354 hand hygiene/washing 97–9 iron 249 psychological self 353 isolation 101 irritable bowel syndrome 164, 166, 172 socio-cultural self 353 protective wear 99 ischaemia 175, 217, 221, 234, 241, 250 sharps 99 ischial tuberosities 262 maceration 253, 256, 262 waste disposal 100–1 isolation – patient 101 macronutrients 139–43 inflammatory response/phase 239–40, MACROS criteria for goals 12, 18 250–1, 256 justice 49, 61, 371, 415 malabsorption syndrome 172 information malnutrition 138, 146, 148 data integrity 451, 463 keloid scarring 252 see also nutrition data recording 463 Korotkoff sounds 223–4, 446 manager data sharing 464 Kussmaul’s respiration 201–2 role in risk management 486–9 data use 463 see also leadership and management electronic patient records 5, 452 laryngospasm 208 management, see leadership, leadership health professional as information last offices 306–7 and management, power, manager 444 laxatives 165, 166, 170, 172, 174 delegation implications for nursing 447–8 leadership manual handling, see moving and informatics at point of care 453–6 achievement orientated 480 handling information governance 460–4 change 471 Manual Handling Operations patients first 450 constructive feedback 484, 485, 488 Regulations 268, 273, 275 systems based approach 449 contingency theory 478–9 managing nursing care who needs information on directive 480 care programme approach 15 health 442–3 emergency versus rountine 479, 483 caseload management 15 informative interventions 27–8, 33 factors influencing 483 client alloaction 14 informed consent, see consent of groups 36 task allocation 14 injections 114–16 maintaining the individual 37 team nursing 14–15 children and babies 120, 122 maintaining the task 37 primary nursing 15 intradermal 123 maintaining the team 36 person-centred planning 15 intramuscular 105, 116–21 motivating 430 management and organisation of subcutaneous 121–2 participative 480 care 456–64 see also medication administration supportive 480 masks, for oxygen therapy 210–12 injuries styles 477–84 meatus 188 associated with moving and autocratic 477 meconium 164 handling 268–9, 275 democratic 477–8 medication administration inspiratory reserve 208 laissez-faire 478 adherence 131–2 interdisciplinary practice theory x or y 482 to children 110, 113, 120, 122, 126, see also interprofessional practice; transactional 481 130, 132–3 multidisciplinary practice transformation 427, 471–2, 488 to clients with learning intermittent claudication 228 see also leadership and management; difficulties 133 internet 442, 453, 455–6 power; delgation; motivation; to clients with Mental Illness 133– interpersonal skills, see therapeutic communication 4 communication leadership and management controlled drugs 106 interprofessional collaboration 395–6 controlling role 484–6 drug plasma levels 109 interprofessional 17 defined 468–9 ears 126–7 changes in service provision 395 directing 475–84 errors in 134 professional socialisation 399–402 objectives or goals 470–2 eyes 125–6 teamwork 397–9, 402–8 organising 472–5 intra-arterial 6 see also interprofessional; primary planning and change intra-articular 6 health-care teams; teamwork management 469, 471 intracardiac 6 intra-articular medication risk management 486–7 intradermal 123–4 administration 110, 113 learning – lifelong 89 intramuscular 116–21 intracardiac medication lifting, see moving and handling intrathecal 6 administration 110, 113 linoleic acid 141 nasal 127–8 intradermal injections 114 linolenic acid 141 via nasogastric tube 112–13 intramuscular injections, see injections lipoproteins 141 nebuliser 128–9 intrathecal medication listening 5, 25, 28–9, 31, 301, 309, 312, nurses’ responsibilities 6 administration 113 315, 362, 364 oral 111 intravenous fluid therapy 235–6 logical and empathic building 28, 30 parenteral 113 inunction 124 loss of self model 353–4 patient assessment before 105 Index 505

prescriptions 106, 108 multiple sclerosis 31, 166, 173, 182, 185, dietary reference values 145 rectal 129–30 336 macronutrients 139–43 right amount 107–9 MUST tool 151 micronutrients 143–6 right medication 107 myopathy as complication of nutrition right patient 109–10 intramuscular injection 120 appetite 147–8 right route 110 myocardial infarction 9, 217, 223 anthropometric measuring 150–1 right time 109 myocardium 217, 231 economic factors 146–7 subcutaneous 121–2 myofibroblasts 240 ethical issues 159 topical 124 nasal cannulae 210 needs 146 transdermal 124 nasogastric tubes plate model 151 vaginal 131 administering drugs via 112–13 political factors 146–7 see also intramuscular injections feeding by 156–8 promoting dietary intake 151–6 meiosis 374, 376, 379–80 public health 146 menstruation 350 National Institue for Health and Clinical role of registered nurse 138–9 Mental Capacity Act 2005 52–3, 133, Excellence (NICE) 454–5 screening and assessment 149–2 276–8, 285, 299–300 National Service Frameworks 435, 448, social factors 146–7 metabolic acidosis 202 459 tips for eating well 153 metered-dose inhalers 212 necrosis 217, 225, 250, 260, 327 nutritional support 156–9 methicillin-resistant Staphylococcus necrotic tissue 255, 260, 262–3 aureus (MRSA) 95–6, 431 needles, for injections 114 obesity 148–9 micronutrients 143–6 nerve damage, as complication of observation, in assessment 6 micturition 170, 185–6 intramuscular injection 121 oedema see also urinary elimination neutrophils 239–41, 250, 253 peripheral 224–5 minerals 139, 143–4 NHS Confidentiality Code of pulmonary 202–4 Mini-Wright’s meter 206 Practice 460 oliguria 226 mitosis 374, 376, 379–81, 388 NHS Constitution 64–5 open questions 6, 30 Misuse of Drugs NHS Direct 448, 462 opioids 302, 336–7, 342–3 Act 1971 105, 321, 325, 333–4 NHS Information Authority 457 oral fluid intake 155, 172, 183 Regulations 1985 324 NHS Knowledge and Skills oral medications 111–12 models, see nursing models Framework 24, 406 oropharyngeal (Guedel’s) airway 208 monoamine oxidase inhibitors 105 NHS Plan, The 394, 405, 425 oropharyngeal suctioning 208, 209 monocytes 239–40 nocturia 179 orthopnoea 201–2 monosaccharides 140 non-judgemental 131, 179, 285, 300, osteomalacia 144 morphine 106, 124, 166, 302, 325, 336 340, 363 overflow incontinence 183, 185, 189 motivation 81, 189, 341, 344, 433, 479, non-maleficence 49, 76, 371 oxygen 485, 488 non-opioid analgesics 302–3 humidification 212 expectancy theory 481 non-starch polysaccharides 140, 143 hypoxia 195 inspirational 472 non-verbal communication 25, 12, 40–1 supplemental 209–10 interviewing 340 Nursing and Midwifery Council (NMC) transportation 199–200 of staff 480 Code of Professional Conduct 3, in wound healing 240–1 theory of 480–1 15–16, 47–9, 53–5, 58–9, 76, 244, oxygen delivery moving and handling 272, 275, 283, 358, 365, 433, 474, face masks 210–12 stability 279–80 475, 477, 485–6 nasal cannulae 210 moving and handling, of patients student nurse accountability 56 communication 282–3 record keeping 55 pain ergonomics 278–9 nursing philosophy assessment 9–10 friction 281–2 Roper et al’s model 7–8, 16 assessment tools/scales 6, 10, 227 Health and Safety at Work Act activities of living (AL) 7 causing constipation 166 1974 12 nursing process 3–7 circulatory problems, see pain from humanistic approach 283–4 assessment framework 7–10 circulatory problems individual capability for 276 data collection 6–7 in respiratory care 204 injuries in NHS 268–9 diagnosis 10–11 symptom control 302 law and legislation 269–78 evaluation in 16–19 in wound management 250, leverage 280–1 implementation 13–16 258–61 Manual Handling Operations planning 11–13 pain from circulatory problems 226–8 Regulations 1992 268, 273, 275 see also assessment; care planning; palliative care risk assessment 284–8 evaluation; implementation; choices and priorities 298 MRSA (methicillin-resistant nursing diagnosis definition 296 staphylococcus aureus) 95–6, 431 nutrients ethical issues 307–10 506 Index

last days of life 305 preparing for a placement 85 morbidity 415 last offices 306–7 prescriptions 106 mortality 415, 429 pain and symptom control 302–3 abbreviations used in 108 nutrition 146 see also dying prescriptive interventions 27, 33 Sure Start 419 panproctocolectomy 175 pressure sores/ulcers (decubitus ulcers) pudendal nerve damage, causing faecal paraphrasing 28, 29–30 96, 239, 242–5, 248–9, 284 incontinence 173 paraplegia 166, 185 assessment tools 246–8 pulmonary oedema 202–4, 225, 234 partial pressure 198–9 classification 260 pulse 6, 10, 205, 218–19, 220–2, 224–5, partnership 3, 63, 354, 361, 364, 365–6, grading 260 229, 234, 256, 336 394–6, 400, 402, 407, 416, 422, 426, risk assessment 261–3 apical 222 430, 433, 477 Primary Care: Delivering the Future bradycardia 220 patient handling, see moving and (White Paper) 404–5 common sites 221 handling Primary Care, General Practice and the Corrigan’s 221 patients NHS Plan 394 hints 220 care record system 451 primary care trusts 394, 405–6, 425, 442 normal rates 220 journey, example 452 primary nursing 14–15 oximeters/oximetry 199, 206, 210 satisfaction 17–18 privacy 32, 54, 112, 116, 124, 130, 169, pulse deficit 222 peak expiratory flow rate (PEFR) 205–6 179, 284, 286, 306, 315, 364, 371, radial 220 pelvic floor exercises 174, 186 373–4, 389, 442, tachycardia 220 perfumes 352 problem-solving 3–4, 257, 398, 402 waterhammer 221 peripheral cyanosis 202, 225 professional accountability 55–6, 271 Punnett square 375, 383–4 peripheral perfusion 219, 224–5 Professional Conduct, Code of 15–16, pus 243 peripheral resistance 222 47–9, 53–5, 58–9, 76, 244, 272, 275, pyuria 186 peripheral vascular diesease 217, 245 282, 358, 365, 433, 474, 475, 477, peristalsis 163, 165–6, 170, 172 485–6 quality 57, 59, 61, 65 personal development plan (PDPs) 90 see also accountability clinical governance 65–6 personal space 40, 286 professional boundaries 49, 393, 398–9, performance and choice 62–4 person-centred planning 15 409 questioning 6, 80, 87, 200, 207, 394, phagocytosis 240 professionalism 243 407, 475 phenotype 380, 382–5 professional practice phenylketonuria (PKU) 384–5 philosophy 48–9 records 55, 117, 122, 124, 127, 130, 421 physical examination 6 responsibilities 48 care planning 4 physical health information 6–7 see also accountability computerised 19, 451–3 physical self, loss of 353–4 professional socialisation 399 as legal documents 3, 16, 56 physician assissted suicide (PAS) 309 promoting health 414, 425, 434 nursing, medical and other 5 planning care, see care planning prostaglandins 239, 249 see also Data Protection Act 1984; Data Plate model 152 prostate gland 179, 183–4 Protection Act 1998 PLISSIT model, nursing intervention and protective wear 99 rectal medications 129–30 sexuality 363–4 aprons 97, 99, 287 rectal prolapse, causing faecal pneumonia 203–4, 327 gloves 97, 99, 111–12, 114, 116, incontinence 173–4 political influences, on diet 146–7 124–8, 130–1, 188, 287 rectoplexy 174 polysaccharides 140, 240 protein 139, 140–1, 164, 239, 248–9, REEPIG criteria for care planning 12–13 population health and well-being 416– 376, 378 refeeding syndrome 148, 155 21 essential 140 reflection Post-registration Education and Practice non essential 140 choosing an experience 78–9 (PREP) 90 sources 141 critical incidents/analysis 76–7, 88 posture, see moving and handling see also amino acids cycle 59 potassium 143, 166, 172 proteoglycans 240 ERA cycle 71 power and authority in leadership and protocols 37, 107, 157, 244, 397, 433–4, evaluation 78 management 476 459, 469 formal and informal 17 practice ethics 48 psychiatric/ psychological factors, causing in-action 59, 73–4 practice nursing key constipation 169 on-action 59, 73–4, 244 developments 405–6 psychological information 7 aradigm cases 71 pregnancy 145, 180, 218, 326, 329, psychological self, loss of 353 personal development plans 90 332–3, 343, 352, 355 Public Health 18 self awareness 300 causing constipation 166 academic 432, 434 simple and selective 29 vitamins during 145 definition 414 skills 74–8 PREP (Post-registration Education and epidemiology 414–15 synthesis 78 Practice) 90 intelligence 432 values 59 Index 507

see also reflective framework and accountability 15, 65 socialisation, professional 399 reflective framework 80–4 resuscitation socio-cultural self, loss of 353–4 reflective ABCDE assessment 200, 207 sodium 143, 172 in practice environment 58, 84–7 cardiac arrest 220, 228–30 specimens practice 58–9, 72 cardio-pulmonary 196, 228–9, 395 collection 165 practitioner 73–5 risk assessment faeces 165 processes 79–80 in moving and handling 271, 275, urine 180–1 portfolios 89–90 278, 284–8 spirituality 312 recording work 87–9 wounds 245–8, 261 biographical aspect 313 see also reflection; reflective framework topical medications 110, 124 definition 313 reflex incontinence 183, 185 rotovirus gastroenteritis 18 moral and biological aspect 314–15 reflux 155 religious aspect 313–14 regulations related to moving and safety 62–4, 66, 99, 129, 133, 181, 233, situational aspect 314–15 handling 272–5, 287 268, 271, 274, 277, 288, 431, 434, 485 sputum 203, 225 religious needs Health and Safety at Work Act types 203–4 diet 147 1974 100, 272–3 stab wounds (punctures) 242 death and dying 313–14 Salmonella 165, 172 stasis elimination 177, 183 sciatic nerve, damage as complication of haemostasis 144, 146, 217, 239 research intramuscular injection 121 urinary 179–80, 185 epidemiology 61, 414 self-esteem and body image 350 venous 233 evidence-based practice/ self-image 249–51, 354–5 steatorrhoea 172 eduction 56–8, 243–4, 305, 363, see also body image stereotype 15, 16 421–4, 454–6 septicaemia, as complication of stockings, anti-embolic (graduated hierarchy of evidence 57 intramuscular injection 120 compression) 233 qualitative 416–18, 423–4, 432 service delivery – changing 64, 402 stoma 100, 163, 354–5, 366 quantitative 416–18, 423–4 sexual health 342, 358, 434 care 174–7 residual volume (RV) 157, 184 sexual orientation 361 colostomy 175 respect 26, 38–40, 49, 62, 64, 277, 284, sexuality ileostomy 175 286, 294, 300, 307, 358, 364, 370–1, assessment 354–7 normal appearance 177 373, 387, 397, 401, 472, 477, 479, 482 desire 362 sites to be avoided 176 respiration gender 360 stoma bags 176 age considerations 205 human 358 cultural/religious issues 177 apnoea 148, 197 modernisation of services 364 stridor 203 assessment 200–4 nurse’s role 354, 359 stroke volume 222–3 Biot’s 201–2 orientation 361–2 student nurses 205, 213, 271 bradypnoea 197, 201 PLISSIT model 363–4 accountability 56 cardio-pulmonary resuscitation 196, and self-awareness 360 subcutaneous injections 108, 110, 395 taboo 358, 364 113–14, 116, 121–2 chemical control of 197–8 vulnerable adults – working children and babies 122 Cheyne–Stokes 201–2 with 362–3 support cough 196, 203 sharps, safe handling, disposal 99 in palliative care 296–7, 300–2 dyspnoea 10, 214 shock 124, 204, 218, 223–5 supportive interventions 33–4 hyperpnoea 202 common causes 218 suppositories 108, 130, 170–1, 174 investigations 205–6 sickle cell anaemia 384 surgical wounds 242, 252 involuntary ventilation 197 sinus arrhythmia 232 SWOT 427 Kussmaul’s 201–2 sinus rhythm 230, 232 symptom control, in palliative care 297, mechanical control 198 six-category intervention analysis 28 302–5 naso-pharyngeal airways 209 skin – cyanosis 6, 199, 202, 224–5 syringes, for injections 99–101, 114 orthopnoea 201–12 infection, health care associated systems based approach to health oxygen delivery 210–12 (HCAI) 96 care 449 positioning 207–8 see also pressure sores; wounds pulse oximetry 206 sleep apnoea 148, 203 tachycardia 172, 220–1, 228, 234, 323, tachypnoea 201 slough 240, 255–6, 260, 262 332, 334, 338 thoracic shape 203 smoking 8, 200, 202, 249–50, 320, 326– tachypnoea 197, 201 see also airway 7, 329, 336, 342, 387, 419, 429, 434 task allocation 14 responses to social behaviour, see assertiveness; groups; Tay-Sachs disease 384 criticism 42 therapeutic communication teams teamworking 407, 409 social influences, on diet 146–7 health-care team members 14, 17 responsibility social loafing 37 maintaining team 36–7 508 Index

working in 404–7 arterial 225, 242, 245 professional 400–1 teamwork diabetic 242 Valuing People (White Paper) 15, 404 definition 397 gastric 331 vasoconstriction 10 endorsing 398 fungating 242 vastus lateralis injection site 117, 119 ethics 401 pressure 6, 96, 239, 243–5, 248–9, vegan diet 142 factors affecting 397–9 258, 260–2, 284 vegetarian diet 142 good practice in 402–4 venous 242, 245, 250 venous stasis 233 interprofessional values 401 unconditional acceptance 24, 26–7, 34 venous ulcers 242, 245, 250 interprofessional as a ‘theory’ for understanding – checking 30 ventilation, mouth-to-mouth, see practice 409 urethritis 179 resuscitation professional boundaries 398–9 urge incontinence ventrogluteal injection site 117–9 professional socialisation 399–402 faecal 173 vitamins 139, 142–3, 145, 156, 249, 258 professional values 400–1 urinary 184–5 vitamin A 250 responses to 407 urinary catheters 95, 96, 187–90, 307 vitamin B1 144, 332 stages in team co-operation 403 catheter size 187 group 250, 332 status of team members 401 indwelling 188 vitamin C 144, 249 support 398 intermittent self-catheterisation 189– vitamin D 144 transdisciplinary 393, 395 90 vitamin E 249 see also interprofessional; primary principles of care 189 vulnerable individuals 51, 53, 147, health-care teams suprapubic 190 285, 301, 356, 366, 371, 419–20, terminal illness 296, 394 urinary elimination 430–1 therapeutic communication 23–7 adolescents and young adults 179 adults, working with 362–3 core qualities 24 adults 179 empathic understanding 25 ageing adults 179 waste genuineness 25 altered 182 categories 100 unconditional acceptance 26 incontinence 182–5 clinical 99 therapeutic skills infants 178 disposal 100–1 catalytic 28 school-aged children 179 sharps 99 cathartic 30–1 specimen collection 180–2 waterhammer pulse 221 confronting 31–3 toddlers to preschool age 178 Waterlow Scale 6, 245–6, 261 informative 33 see also urine specimens weight listening 28 urinary incontinence 182–5 limitations – moving and prescriptive 33 urinary stasis 179–80, 185 handling 275–6 six-category intervention analysis 28 urinary tract infection (UTI) 173, 179, World Health Organization (WHO) supportive 33–4 184, 189–90 analgesic ladder 302–3 thiamin (vitamin B1) 7 urine collaborative practice definition 393 three circles model, of leadership 36 checking fluid intake 8 health, definition 415 thrombophlebitis 235 colour 181 wound thrombosis 121, 327 odour 181 acute wound environment 241 deep vein thrombosis (DVT) 218, 232 urine specimens 180 care planning 257–64 tidal volume 208, 211 24-hour collection 180 chronic wound environment 241 tissue viability 239, 243 catheter specimen of urine (CSU) 180 classification 242 topical medications 124 early morning urine (EMU) 180 healing process 239–43 see medicine administration midstream specimen of urine complications 251–2 touch 6, 31–2, 34, 40, 306, 312, 314, 363 (MSU) 180 factors affecting 248–51 transactional analysis 38 principles of collecting 180 optimum environment 253–6 transdermal medication routine screening 181 pressure ulcers 11 application 124–5 urostomy 185, 190–1 risk assessment 245–8 transdisciplinary teamwork 393 UTI (urinary tract infection) 173, 179, wound assessment 257–64 trans-fats/fatty acids 141–2, 249 184, 189–90 wound exudate 239, 251, 253–6, 260, treatment – withholding and utilitarian 401 262–3 withdrawing 307–8 wound healing trisomy 381 Vacuum-assisted Closure (VAC) 255 abnormal 252 Down Syndrome 169, 381 vaginal medications 110, 141 contractures 252 triglycerides 141 Valsalva manoeuvre 185 hypertrophic scarring 252 tuberculosis 431 value keloid scarring 252 based practice 60–1 malignant disease 252 ulcerative colitis 172–3, 175 interprofessional 401 overgranulation 252 ulcers personal 400 cell reconstruction 249 Index 509 clinical governance framework 244 cardiovascular and respiratory haemostasis 239 complications 251–2 status 250 inflammatory 239–40 abnormal healing 252 nutritional status 248 maturation 240–2 dehiscence 252 pain 250 proliferative 240 haematoma 252 smoking 250 wound management case study 257–64 heamorrage 252 stress 251 Wright’s meter 206 infection 251 modes of 242 dressings 253–6 primary intention 242 zinc 143, 250 epithelialisation 240–2 secondary intention 242–3 Z-track intramuscular injections 120 exudate 251, 253–6 tertiary intention 243 zygote 375, 380–1, 383 factors affecting 248–51 optimum environment 253–5 age 250 phases 239–42